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Study
reveals next day follow-up visit may be unnecessary for most cataract
patients
By
Cheryl Guttman
Fort Lauderdale - Skipping the traditional follow-up visit the day
after surgery does not adversely affect the outcomes of patients
undergoing uncomplicated phacoemulsification surgery, according
to a new prospective randomised study.
Researchers from Musgrove Park Hospital, Taunton, UK, evaluated
outcomes for 188 patients randomised to same day discharge (SDD)
with a first follow-up visit scheduled at two weeks postoperatively
and 174 patients assigned to next day review (NDR) with the second
planned follow-up after two weeks.
In the NDR group, 21 (12%) patients received altered management
at day one with oral acetazolamide treatment for raised IOP being
the most common intervention (n=14, 8%). Other complications included
marked corneal oedema and uveitis, each occurring in two eyes. One
patient had a wound leak, another had exposure requiring treatment
and one had a loose suture removed.
Twelve extra visits occurred prior to the 2-week visit, primarily
for symptoms related to eyedrop use or for IOP follow-up.
In the SDD group, there were seven extra visits prior to the second
week follow-up, including three for patient reassurance. Iris prolapse
detected in a single eye was the only potentially serious complication
noted at the two-week visit, but it did not require surgical intervention
or result in poor acuity.
Stratified randomisation
Randomisation was stratified according to whether patients were
having first or second eye surgery. Patients in the SDD group had
their eye pads removed two to three hours after surgery and received
discharge counseling and medication. Patients in the NDR group went
home with the eye padded and returned the next morning for slit
lamp review.
The exclusion criteria eliminated patients with a single sighted
eye, those undergoing concomitant surgical procedures, categorised
as ASA Grade III or worse, or those deemed to have insufficient
social support to be cared for overnight at home.
The protocol allowed the surgeon or anaesthetist to override patient
allocation; 13 SDD patients were assigned to return for next-day
review and one NDR patient was seen for initial follow-up on the
day of surgery. Four of the 13 SDD patients required an alteration
in standard management at the Day 1 visit for either elevated IOP
or corneal oedema.
Researchers noted no significant differences in objective and subjective
visual outcomes. Snellen visual acuity of 20/40 or better was present
in 83% of eyes in both groups at week two, reported Christopher
Tinley MB, ChB, at this year's meeting of the Association for Research
in Vision and Ophthalmology.
Responses to the Vision Core Module 1 (VCM-1) questionnaire, which
was mailed four months after surgery, showed approximately 70% of
patients in both groups had scores less than 1.0, indicating none
or little concern about vision.
"Any conditions which may have been present in our SDD group
on the first day after surgery did not result in detectable adverse
consequences, despite going untreated.
"However, we estimate that eliminating the traditional Day
1 postoperative visit in patients having routine phacoemulsification
surgery would save approximately 1,000 visits for eligible patients
going through our department in the six month recruitment period.
That practice, therefore, has significant cost- and labour-saving
advantages without compromising patient safety or visual outcomes,"
Dr Tinley said.
He noted that previous papers on this topic, consisting of retrospective
studies and prospective, nonrandomised trials, report complication
rates of 3% to 41% among patients seen on the first day after phacoemulsification.
The authors of those various articles suggest the main reasons for
scheduling a next-day review are that it provides the opportunity
to treat raised IOP and detect early, potentially sight-threatening
complications, such as iris prolapse.
Long-term visual function
"There is no current evidence, however, that treating transient
postoperative IOP spikes influences long-term visual function. In
addition, there were no cases of iris prolapse seen on day one in
the NDR group in our study population and of two cases that occurred
in the SDD group, one was anticipated in a patient having complicated
surgery and was not detected until day three despite earlier follow-up.
"The second case of iris prolapse may or may not have been
present on day one," Dr Tinley explained.
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